accreditation essentials - aacd
TRANSCRIPT
accredi tat ion essentials
IN THIS SECTION: • Clinical Case Report: Complex Composite Resin Bonding page 59
• Interview with the Candidate page 67
• Newly Accredited Member page 68
CLINICAL CASE REPORT:
COMPLEX COMPOSITE RESIN BONDING
n A. Stratta, D.M.D.
Dr. John Stratta is a graduate of Fairleigh
Dickinson University School of Dental
Medicine, where is was elected into the OKU.
He graduated from the New York University
(NYU) School of Dentistry post-doctoral pro-
gram in prosthodontics. He also served as a
faculty member at the NYU School of
Dentistry for 20 years. He has maintained a
full-time private practice in New York focused
on esthetic, prosthetic, and implant dentistry
since 1965. Dr. Stratta served a 2-year tour of
duty as a Captain in the U.S. Army Dental
Corps as a prosthodontist. He has attained
advanced training certification in gnathology,
Schyler Panky Dawson traditional occlusion,
implant prosthodontics, microdentistry, and
esthetically based cosmetic dentistry, and is
currently training in neuromuscular occlusion.
He also maintains memberships in many pro
fessional societies, organizations, and acade-
INTRODUCTION
The Class IV defect presents the cosmetic dentist with an esthetically chal
lenging and restoratively demanding treatment procedure that requires insight
into the following areas:1'6
occlusal force distribution
parafunctional habits
coronal morphology
material compatibility properties
polychromicity
texture
finish line boundary camouflage
shade selection analysis
polymerization shade behavior shifts
adhesive restorative materials
polishability
maverick colors.
The evolution of anterior restoratives from the archaic silicates and methyl-
methacrylate acrylics to the current generation of sophisticated composite
resins and adhesives means that clinicians now have restorative materials with
which to mimic the esthetic appearance of a natural tooth while simultane
ously preserving, as well as reinforcing, the restored tooth.7,8
Treatment with such a conservative approach creates challenges in select
ing and combining composite resins that chameleonize with the polychromic
ity of enamel and dentin. They also present an opacity challenge to simulta
neously mask the existence of an internal restorative interface and the exter
nal restorative margin.9
VOLUME 18 • NUMBER 1 SPRING 2002 • THE JOURNAL OF COSMETIC DENTISTRY 59
accredi ta t ion essent ia ls
Figure 1: Before, full smile frontal view, Figure 2: After, full smile frontal view, 1:2 magnification, non-retracted view. 1:2 magnification, non-retracted view.
H I S T O R Y
The patient is a 42-year-old male
with no significant medical history. He
presented with a traumatic injury to
the left central incisor. The brother of
a goalie for the New York Rangers, the
patient had participated in a team
practice session when he felt a sudden
mild bumping, which would have gone
unnoticed except for pieces of shat
tered tooth in his mouth. He experi
enced no pain and there was no injury
to the lips or soft tissue. There was no
bleeding and the tooth felt firm. His
chief complaints were sharpness of the
remaining tooth, a lisp when speaking,
and concern for his appearance. The
patient wanted to leave the office
expeditiously with a natural-looking
restoration.10 The treatment option of
choice was a direct resin-bonded Class
IV restoration.
D I A G N O S I S A N D T R E A T M E N T P L A N
A complete examination and full
series of radiographs were performed,11
revealing five amalgam restorations,
two molar porcelain-fused-to-metal
crowns, the absence of carious lesions,
the coronal fracture of #9, no root frac
ture, no periodontal ligament space
thickening and a 0.5 mm thickness of
dentin remaining incisally to the pulp
chamber. Endodontic vitality tests
with electrical, thermal, and percus
sive stimuli revealed positive pulpal
vitality. Periodontal survey revealed a
healthy periodontium.
The occlusal forces to the
composite created during anterior
guidance functional movements
are best mitigated by directing
the force vectors to the composite
parallel to the remaining
enamel rods.
Photographic documentation was
made following the AACD
Accreditation protocol with Kodak
Ektachrome 100 EPN 35 mm slide
film. Additionally, representative
Vitapan 3D (Vident; Brea, CA) and
composite shade tabs were pho
tographed with Polaroid film for refer
ence during treatment procedures
(Figs 1-10). Maxillary and mandibular
alginate impressions were made for
pretreatment study casts. A Denar
(Teledyne Water Pik; Fort Collins,
CO) semi-adjustable facebow transfer
with facial horizontal plane level
allowed the casts to be mounted on a
Denar semi-adjustable articulator in
centric occlusion.12 Definitive occlusal
treatment was not feasible at this
emergency appointment; however, an
interceptive soft orthotic was possible.
The polychromicity of enamel and
dentin was moderate, with the enamel
being mildly opaque. This is consistent
with bleaching, which has the tenden
cy to soften and blend polychromici
ty.13 The surface texture appeared
smooth and worn, with slightly con
cave developmental grooves. There
were vertical surface craze lines, which
were positive to the explorer. There
were multiple vertical internal enamel
crazing lines of varying lengths and
patterns in the left central and in the
adjacent incisors. The combination of
surface developmental grooves and
dominant axial ridges, along with sur
face and internal crazing characteris
tics, provided a favorable condition to
camouflage the external marginal fin
ish line.4
60 THE JOURNAL OF COSMETIC DENTISTRY • SPRING 2002 VOLUME 18 • NUMBER 1
accredi tat ion essentials
Figure 3: Before, right lateral view, 1:1 magnification, retracted view.
Figure 4: After, right lateral view, 1:1 magnification, retracted view.
Figure 5: Before, left lateral view, Figure 6: After, left lateral view, 1:1 magnification, retracted view. 1:1 magnification, retracted view.
An initial shade analysis was per
formed under various conditions using
the Vitapan (Vident) 3D shade
guide14,15 and the chromatic chart (Fig
11) described by Vanini;16; and with
custom, in-office fabricated tabs from
several brands and types of composite
with both polished and non-polished
surfaces.4
Occlusal analysis for parafunctional
effects such as wear facets, cervical and
cuspal abfractions, gingival recession,
exostosis development, and incisal
guidance integrity revealed positive
findings in a majority of these areas.
There was the loss of canine-protected
occlusion bilaterally with erosive pos
terior and anterior excursive contacts.
There was slight labialization and rota
tion of the mandibular central incisors
and left lateral which, when coupled
with the parafunctional activity, could
further compromise the restoration.
The occlusal forces to the compos
ite created during anterior guidance
functional movements are best miti
gated by directing the force vectors to
the composite parallel to the remain
ing enamel rods. This will be accom
plished by developing the angle of the
faciolingual inclination of the incisal
edge so that the interface of the
mandibular incisal edges with the
restoration will be parallel to the rods.
The lingual surface of the restoration
will also be contoured so that the
incline angle of the surface will simi
larly redirect the force. Interceptive
methods will be utilized to neutralize
the noxious effects of prolonged para
functional habits. Canine-protected
guidance will be re-established
through the direct bonding of judi
ciously applied microhybrid composite
to the guidance pathways of the maxil
lary and mandibular canines.1 A
removable occlusal orthotic will be
fabricated for nocturnal bruxing pro
tection and habit abatement.2
VOLUME 18 • NUMBER 7 SPRING 2002 • THE JOURNAL OF COSMETIC DENTISTRY 61
accredi tat ion essent ia ls
Figure 7: Before, upper arch occlusal view, 1:1 magnification, retracted view.
ARMAMENTARIUM
• 37% Phosphoric acid etch
Fortify (Bisco; Shaumburg, IL)
• Burs: black diamond 836-012,
849-014 (SS White; Lakewood,
NJ); gold diamond 2878-313-
014 (Brasseler; Savannah, GA);
finishing diamonds 134F-014,
134EF-014, 134UF-014368UF-
016, (Brasseler); 12 fluted ET3,
ET6, OS1, OS2, carbide H282-
102 (Brasseler)
• Vitapan 3D Shade Guide
(Vident; Brea, CA)
• Vitalescence Shade Guide
(Ultradent; South Jordan, UT)
• Composite resins: Filtek Z-250,
B5, UD, AID, IL (3M;
Minneapolis, MN); Filtek
A110, A1E, A2, B1 (3M);
Esthet-X A-10 (Dentsply/Caulk;
Milford, DE); Durafill Bl, Al,
A2 (Heraeus Kulzer; Armonk,
NY); Vitalescence Tl, PS, PF
(Ultradent); Renamel Hybrid
B-l, Microfill A-l (Cosmedent;
Chicago, IL)
• Articulating film (Moyco; York,
PA)
• Composite placement instru
ments (Cosmedent): IPCL
62 THE JOURNAL OF COSMETIC DENTISTRY • SPRING 2002
Figure 8: After, upper arch occlusal view, 1:1 magnification, retracted view.
VOLUME 18 • NUMBER 1
(long-bladed extra-thin), 8AL
(long-bladed), Multiuse, IPCT
(short-bladed extra-thin)
• Goldfogel contouring instru
ments (Hu-Friedy; Chicago, IL):
straight -MG1, curved-MG3
• Brush #1, Resin Keeper, Flexi
Buff, Enamelize (Cosmedent)
• Hollenbeck instrument,
Wiedelstat chisel (Hu-Friedy)
• Ultrabrush Plus disposable
brush, Jiffy brushes (Ultradent)
• Microbrush, regular, applicator
tip (Microbrush; Grafton, WI)
• KolorPlus tints and opaquers
(Kerr; Orange, CA)
• Creative Color tints and opa
quers (Cosmedent)
• Boley gauge (Sullivan Shien;
Melville, NY)
• Clearfil SE Primer and Bond (J
Morita; Irvine, CA)
• Microsurgical scalpel knife
(Microsurgery Institute; Santa
Barbara, CA)
• Compostrips (Premier; King of
Prussia, PA)
• Abrasive polishing brushes
(Premier)
• Concepsis (Ultradent)
• Denar articulator, facebow
(Teledyne Water Pik; Fort
Collins, CO)
• Epitex finishing strips (GC;
Alsip, IL)
• Sof-lex disc (3M ESPE, St. Paul,
MN)
• Flexipoint cups and wheels
(Cosmedent)
Manipulating composites,
whether from a syringe or unit
dose compule, may result in
porosity.
RESTORATIVE TECHNIQUE
Special care and attention was
given throughout all clinical proce
dures to scrupulously maintain hydra
tion of the dentition. The teeth were
supragingivally debrided of plaque,
stain, and calculus with sonic scaling,
powdered prophy jet, and rubber cup
polishing with a slurry of Concepsis-
moistened fine pumice.3
The initial shade selections were
reconfirmed and several refinements
were made. Numerous shade analysis
accredi ta t ion essentials
Figure 9: Before, frontal view, Figure 10: After, frontal view, 1:1 magnification, retracted view. 1:1 magnification, retracted view.
T A B L E 1 - S H A D E O B S E R V A T I O N S Vitapan 3D shade guide was recorded as:
Value: 1M1 Chroma: 1L1.5 Hue: 1/2 OM1 + 1/2 1L1.5
Chromatic Chart of Vanini provided numerous categories and visual representations of the five color dimensions within teeth.16 This chart of selections resulted in a workable nicely layered mapping, which was recorded as:
Chromicity 1/2 OM1 to 1/2 1L1.5
Value 3 - Youth- High
Intensities 1 W small white stains
Opalescence Type 3 comb like Grey B Type 5 triangle mid incisal, Low chroma amber
Characterization Type 5 vertical crack white
The final observations were made with a variety of proprietary and custom composite resin shade tabs. This provided the ability to correlate the standard ceramic convention of color units into a corresponding composite color. This conversion fine-tuned the comparison of composite color to tooth color resulting in the composite selection listed:
Filtek Z-250 Hybrid B.5, Bl, UD, AID, IL
Filtek A110 Microfill A1E, A2, Bl,
Renamel Hybrid Bl
Renamel Microfill A1
Vitalescence TI, PF, PS
Durafill Bl, Al, A2
systems exist that attempt to commu
nicate the variety of colors present in
vital teeth.13 A combination of three
detailed systems was selected. Each
proprietary system provided an accom
panying prescriptive form, which facil
itated organizing and tracking the
color findings. The observations made
with these systems are outlined in
Table 1.
The visualization of restorative
color is influenced by the variables
found between the single tooth, con
tralateral teeth, the palatal intraoral
dark zone, the gingival tone, the lips,
the skin, and the eyes. It is possible to
create a "trompe l'oeil" illusion in
color and in form which, when viewed
at all angles, distances, and lighting
will preclude any detectable evidence
of artificiality.17
Historically, the creation of the
dental ceramic restorative illusion has
been accomplished through the
"ordered stratification" (as described
by Geller) of colors and materials into
definite discreet layers with deeper
internal opaque layers, followed by
serially stratified layering of increas
ingly translucent and transparent
materials. In an important revision to
this technique, known as "ordered dis
order stratification," Geller recom
mends the placement of more translu
cent layers under opaque layers, as well
as placing multiple opacities, colors,
and translucencies discretely through
out the layers of the restoration to
develop a "color contrast effect." This
VOLUME 18 • NUMBER 1 SPRING 2002 • THE JOURNAL OF COSMETIC DENTISTRY 63
accredi ta t ion essent ials
CHROMATIC CHART
Figure 11: Chromatic chart.
facilitates the transmission of light
inside the restoration, creating the real
visual depth and illusionary depth
characteristic of natural teeth. The
objective, then, is to incorporate with
in the restoration a disorder of layers,
hue, chroma, value, opacity, intensi
ties, and characterizations to more
closely approximate nature.18
Anesthesia was used and a double-
layered modified rubber dam was
abutted to the second premolars,
exposing the teeth and gingiva while
retracting the lips, cheeks, and tongue.
The under-layer of rubber dam19 was
sealed to the mucosa for saliva control.
The outer layer created a tension
envelope between the layers to retain
moistened gauze strips over the
exposed non-operative teeth. These
teeth were kept moistened to permit
shade-matching verification during
composite placement.
The unsupported enamel and dam
aged dentin were removed with a
Wiedelstat chisel (Hu-Friedy). The
distal contact was opened using a fine
diamond bur and matrix band to pro
tect the approximating surface.
Anticipating the most advantageous
area for creating a disappearing finish
line was then evaluated. The intention
was not to overstep the bounds of a
Class IV and create a veneer, so a pen
cil outline of the intended margin was
made, taking into consideration sur
face texture, grooves, ridges, and
reverse heights of contours, which
would camouflage the enamel-com
posite interface, reflect light into the
enamel away from the visible path,
and give the optimal accessibility for
finishing and polishing.3,4
A modified chamfer-type bevel
approximately 2.5 mm in width and
graduating in depth from 2 mm at the
fracture line to 0.2 mm at the margin,
was made following the pencil outline.
On the lingual surface, the margins
were kept parallel to the enamel rods.
A Mylar matrix was placed to pro
tect the adjacent proximal surfaces and
37% phosphoric acid gel was applied
to the enamel for 15 seconds, to the
dentin for 10 seconds, and then rinsed
for 30 seconds. The excess water was
absorbed by blotting with 2 mm square
tissue sponges and #60 absorbent paper
points, leaving a moist dentin surface.
Self-etching primer Part A was applied
for 20 seconds and light-cured for 20
seconds with an Optilux halogen light.
The adhesive bonder Part B, a 10%
filled resin, was applied and agitated
with a Microbrush for 20 seconds, then
air-dried for 20 seconds with a gentle
dry air stream held 1 cm away.
Attention was given to visually con
firm the presence of a thin layer of
adhesive and the absence of puddling.
The Mylar matrix was removed to pre
vent a thick puddling of the resin at
the margins and to maintain and
intact the air-inhibited surface at the
margin. The adhesive bonder Part B
was light-cured for 20 seconds.
Manipulating composites, whether
from a syringe or unit dose compule,
may result in porosity. This was obviat
ed by cutting the composite into very
small increments, which were then
vigorously rolled into balls on a coated
pad with an alcohol-cleaned gloved
finger. Inclusions such as gauze fibers,
cotton dust, and other foreign bodies
were also avoided. Brushes were not
used to shape the composite because
they increase the risk for the occur
rence of inclusions, porosities, interfer
ence with the air-inhibited layer, and
surface dilution by wetting agents.
The palette of composites was
organized into the anticipated order of
use beginning with the hybrids, fol
lowed by microhybrids and microfills.
Each was arranged in a descending
order of opacity, value and hue on the
covered Resin Keeper (Cosmedent).
The less viscous modifying opaquers,
tints, and colors were arranged in the
wells along with a crystal-clear unfilled
resin for diluting purposes.
The initial 0.5 mm increment of
high opacity and high value Z250 B.5
was placed at the pulpal floor for pro
tection and polymerized. Additional
small increments of the same hybrid
shade were sequentially applied and
polymerized, forming the central core
of the restoration.''8 The core was
approximately 0.7 mm in thickness,
0.7 mm short of lingual occlusion, and
0.5 mm short of incisal edge position.
The lingual surface was concave
inciso-gingivally to approximate the
lingual anatomy, the incisal edge was
64 THE JOURNAL OF COSMETIC DENTISTRY • SPRING 2002 VOLUME 18 • NUMBER 1
accredi ta t ion essentials sculpted into an irregular anatomy to
simulate mamelons, the facial surface
had a straight emergence profile from
the dentin at the juncture of the denti
nal fracture line, and the internal
bevel and slight hints of vertical
mamelon-like grooves were sculpted.
Care was taken to continuously
observe the thickness and faciolingual
position of the core through a mirror
view to prevent overcontouring.
Throughout this operative
procedure, the adjacent teeth
were repeatedly referenced for
value, hue, and shape
comparisons by lifting the
moistened gauze that maintained
hydration.
Camouflaging the fracture line and
raising the value of the hybrid core
necessitated the use of opaquers. A
thin dabbing of Creative Color Al-
Bl- LO Pink (Cosmedent) with a #1
brush was spotted over the tooth-com-
posite interface and polymerized.
KolorPlus A1 (Kerr) was then similar
ly spotted to create variation in value
and chroma. These opaquers were not
applied as total cover layers; rather,
they were applied lightly and in a spot
ty manner and polymerized in multiple
applications to mimic stratification.3,4
Esthet-X A1 (Caulk) was placed
over the lingual of the Z250 central
core and polymerized. The core was
completed incisally with the addition
of small increments of Vitalescence
Tl, PS, and PF (Ultradent), resulting
in a mildly discernable incisal demar
cation of the various shades. The high
value PS shade of composite was
placed at the linguo-incisal edge form
ing the incisal halo. The middle one-
third of the opaqued core was then
thinly layered with Z250 UD.
Renamel Hybrid B1 (Cosmedent)
formed the lingual half of the contact
area. Small increments of Z250 A1
and B2 were placed, followed by
another thin spotting of KolorPlus A1
opaquer. Observing the restoration
from a mirrored incisal view revealed
that it encompassed only one-half of
the available facial lingual thickness.
The initial enamel layer was applied
as a blend of Filtek A110 microfill A1
and A2 (3M), and a thin coating of
Creative Color honey yellow tint
(Cosmedent) was applied to the mid-
incisal area. Small white intensity
spots at the mesial and distal line
angles were created by the application
of diluted KolorPlus white opaque.
The fine craze lines were created by
forming an extra-thin groove in the
cured microfill with a microsurgical
scalpel blade, into which was placed a
minute amount of diluted KolorPlus
white and ochre tints. The surface
enamel layer was created with
extremely small pellet-like amounts of
Durafill shades Bl, Al, A2 (Heraeus
Kulzer); and Filtek A110 shades Al
and A2E (3M), utilizing their differ
ences in opacity and value to create a
stratified effect.20
F I N I S H I N G
Throughout this operative proce
dure, the adjacent teeth were repeat
edly referenced for value, hue, and
shape comparisons by lifting the mois
tened gauze that maintained hydra
tion. This made it possible to immedi
ately predict the result of the restora
tive procedures by eliminating the
necessity to wait for rehydration. The
restoration was carefully examined,
then extensive additional polymeriza
tion was accomplished to ensure max
imum conversion of the composite
resin.
The rubber dams and gauze strips
were removed. First, centric occlusion
functional contacts were developed
using blue articulating film. Then pro
trusive functional slides were marked
with red articulating film and adjusted
into harmony with the neighboring
anterior teeth. These adjustments were
made with a 12 fluted OS1 bur
(Brasseler). The facial surface was
smoothed with 12 fluted ET3 and ET6
burs and the incisal edge was smoothed
with a fine Sof-lex disc (3M ESPE).
The composite surfaces extending 0.5
mm beyond the margins were etched
for 10 seconds, rinsed, dried, and coat
ed with a protective layer of Fortify
(Bisco). To allow for complete devel
opment of the enamel/dentin bond
strengths and for maturation of com
posite polymerization strength, the
patient was instructed to return in 2
days for final finishing and polishing.
The first step at the finishing and
polishing appointment was to contour
the overall shape with the use of 12-
fluted ET3, ET6 burs, as well as medi
um and fine Sof-lex discs. The second
step followed with the careful shaping
of the distal contact area to create ade
quate embrasure form and line angles.
This was accomplished by placing a
separating wedge and carving into the
embrasure and proximal line angles
with a microsurgical scalpel and a #12
scalpel. The wedge was removed and
proximal stripping, shaping, and pol
ishing was accomplished with an
extra-fine metal strip followed by
Epitex strips (GC) progressing from
medium to superfine. The third step
VOLUME 18 • NUMBER 7 SPRING 2002 • THE JOURNAL OF COSMETIC DENTISTRY 65
accredi tat ion essentials involved the marginal interface of
enamel to composite, requiring truly
concentric rotary instruments free of
chatter, sharp instruments, and keen
observation of the existing anatomy.
The locations of grooves and ridges
were highlighted by pencil marks on
the enamel and carved into the com
posite. The contouring and carving
extending the anatomy into the com
posite was done with 12- and 30-fluted
pointed, flame-shaped, and football-
shaped carbide burs. Carbides were
used because they impart characteris
tic subtle secondary facets in the
microfill composite, which at the pol
ishing stage will be made to resemble
tertiary texture and provide light-
reflecting surfaces.4 Ultra diamond
burs, which are more easily controlled,
result in a more matted flat surface
devoid of texture. In the fourth step,
the primary anatomy (grooves and
ridges), secondary anatomy (facets),
and tertiary anatomy (texture, cracks,
and crazes) are carried incisally from
the margin into the body of the
restoration. The same instrumentation
was employed as was utilized in step
three.
The fifth step addressed the incisal
edge and lingual surface anatomical
morphology. The final length adjust
ment to the incisal edge and embra
sures was made by closely observing
the contralateral central. The incisal
edge was trimmed to coincide with the
incisal guidance in a faciolingual incli
nation. A wear facet irregularity was
located to reflect similar wear patterns
on other teeth. In incisal mirror view,
the facial surface anatomy was evaluat
ed and the faciolingual width of the
incisal edge was compared to the
adjoining central and reduced from the
lingual. The cingulum, lingual groove,
and marginal ridges were carved and
contoured with 12-fluted ET3, OS1,
OS2 burs and were refined with ultra-
diamonds.
Finally, the sixth step was polishing.
The most common definition of pol
ishing, yet the least desirable, is to
obtain a high luster by developing a
flat surface. True esthetic polishing
results in multifaceted high-luster sur
faces that maintain the subtle features
of primary, secondary, and tertiary
anatomy. The microfill surfaces were
polished with Cosmedent blue and
pink rubber points and cups, followed
by a cylindrical goat's hair brush to
reach the tertiary anatomy and enam-
elize paste on a felt-sided Flexi Buff
(Cosmedent) run at a very high speed.
The microhybrid which formed the
lingual surface was polished with
Flexipoint cups and wheels
(Cosmedent), followed with a Jiffy
polishing brush (Ultradent) for final
high-gloss polish.
S U M M A R Y
Composite breakthroughs give the
clinician state-of-the-art materials
with which to create predictably func
tional and esthetic Class IV restora
tions. However, the ultimate esthetic
result will not be achieved without
implementation of a proper protocol.
This case demonstrates a very specific
stepwise method to implement a pre
dictable methodology for the incre
mental application of varying compos
ite resins and modifiers in a disordered
stratification to transform a Class IV
fracture into a final restoration that
mimics nature and is in harmony with
the total dentition.
For the cosmetic dentist, exquisite
esthetics is a reachable quest. .Jip
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